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Cases & Commentaries
- Web M&M
Harold S. Kaplan, MD; February 2004
Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.
Journal Article > Commentary
Ciçek MC, Köksal G, Özdemirel NE. Total Qual Manag Bus Excel. 2005;16:331-349.
The authors present a model that supports feedback processes for total quality teams to facilitate effective measurement of their efforts. The model was tested on a health care team, and results are discussed.
Journal Article > Study
Ursprung R, Gray JE, Edwards WH, et al. Qual Saf Health Care. 2005;14:284-289.
This pilot study evaluated the feasibility of using a safety auditing checklist during daily work in an intensive care unit. Investigators developed a 36-item list focused on errors common to this clinical setting and implemented them into rounds on a regular basis for the 5-week study period. Results suggested the ability to detect a variety of errors while engaging staff in a blame-free fashion to stimulate immediate changes in performance. The authors advocate for greater application of safety and error prevention methods into routine clinical work as a mechanism for ongoing quality improvement.
Journal Article > Review
Shah RK, Roberson DW, Healy GB. Curr Opin Otolaryngol Head Neck Surg. 2006;14:164-169.